Cognitive Behavioral Therapy for Social Anxiety

Social anxiety disorder (SAD) is not only marked by difficult emotions, such as fear, shame and sadness, but also by highly negative thoughts and harmful behavioral patterns.

Many experts believe that the negative cognitions as well as the strong tendency to avoid feared social situations do not only lie at the core of social phobia, but are the main reason people develop it in the first place.

Cognitive behavioral therapy (CBT) addresses these maladaptive patterns and attempts to change them, which can lead to significant reductions in social anxiety.

As of today, it is regarded the treatment of choice for SAD. In this article, we will have a closer look at why this is the case and break down its essential parts for you.

How Does CBT Explain Social Anxiety?

To better understand how CBT works and why it can help you reduce your social anxiety, let’s first have a look at the cognitive model of SAD. There are several, but here we will focus on the most commonly applied one.

It was developed by the psychologists David Clark and Adrian Wells in 1995. According to their model, a specific social situation provokes negative, often even catastrophic thoughts.

In most cases, the affected person can recall a similar situation that happened in the past, which resulted in a traumatic social experience. Because of that, negative memories are triggered and bring about catastrophic thoughts, such as “I will make a fool myself and this will be horrible”.

At this point, a negative feedback loop starts to arise. Have a look at the following graphic and see how negative thoughts, self-consciousness, anxiety symptoms, and safety behaviors tend to reinforce each other.

Let’s say a person named Erica was laughed at while giving a presentation at school during her teenage years. Now, a whole decade later, she is asked to give a presentation to her colleagues at work.

As Erica stands in front her co-workers, she is reminded of her traumatic experience, which triggers negative thoughts.

“Oh my god, what if all of them laugh at me just as it happened back at school? I must avoid looking anxious or they will think I am weird and make fun of me.”

Now, Erica becomes self-conscious, meaning that she focuses on herself and how she might be seen by the others.

She feels her anxiety cropping up, noticing how her heart is beating considerably faster and how her face is getting hot. In her mind, she constructs a mental picture of how she might appear from the outside. This, in turn, triggers more negative thoughts.

“They can tell how nervous I am. They can see that I am blushing, that my hands are shaking, and they must be noticing how my voice is cracking. I must control my anxiety.”

At this point, Erica starts to make use of so-called safety behaviors. She does so in an attempt to prevent her imagined worst-case scenarios and to limit the potential damage caused to her public image. She starts to:

• lower her head in an attempt to prevent people from seeing her blushed face;
• hold on to her notes very strongly to prevent her colleagues from seeing her hands shake;
• speak at a low volume so the others don’t hear her voice cracking up;
• try to suppress her anxiety and the physical sensations associated with it.

However, although Erica is convinced these strategies are helping her avoid the feared outcomes, they reinforce her self-conciousness and even increase the likelihood of her seeming insecure.

Because Erica is overly focused on herself instead of the task at hand (giving the presentation), her objective performance suffers.

Additionally, her expectation of a negative outcome makes her lose sight of any social cues that could lower her anxiety, such as her co-workers nodding with approval to the things she is saying.

By attempting to suppress the physical manifestations of her anxiety (such as her blushing or her shaky hands), they are likely to be reinforced. The more stress and anxiety Erica experiences, the more likely she is to fall prey to this psychological paradox.

When looking at the graphic above, you probably noticed an arrow from the safety behaviors back to the initial, negative-thoughts-provoking situation. Here it is again.

This arrow is of particular importance, as safety behaviors, especially outright avoidance of the feared situations, tend to maintain social anxiety over time. As you will see in just a moment, treatment addresses this part of the feedback loop.

Unlike many socially anxious people, Erica does not avoid giving the presentation, which is an important step into the right direction. However, her safety behaviors get in the way of making a positive, corrective experience that could lower her anxiety in similar situations in the future.

Paradoxically, safety behaviors often lead to the exact same thing they intent to prevent. For example, holding on tightly to her notes may lead to even shakier hands as Erica progresses with her presentation.

By lowering her head and avoiding direct eye-contact, she is more likely to seem insecure than when speaking with her head up straight.

By attempting to suppress her blushing, she is likely to blush even more intensely. By not speaking loudly, she seems even more intimidated and someone may ask her to speak up a little.

All of this does not only seem to confirm her negative beliefs about the dangerousness of this social setting, but it also increases her fear of being in a similar situation in the future.

For Erica, this means that as soon as she is told to give another presentation at work, her anxiety will set in, even though the presentation lies two weeks in the future. Socially anxious people often suffer from such a fearful anticipation of social events.

Likewise, people with SAD often engage in excessive rumination about social situations that lie in the past. Psychologists refers to this behavior as post-event processing.

In our example, Erica would play the presentation through in their head, over and over again. She would recall her performance more negatively than it really was and she would overestimate the social costs of appearing nervous and insecure in front of her co-workers.

Have a look at this short animation and note how anticipatory anxiety and post-event processing affect people with SAD, even when they are not in a social situation they fear.

Ruminating about past social events and doing so with a negatively biased view (seeing it as more negative and consequential than it really was) reinforces and even aggravates the anticipatory anxiety about future situations.

At this point, a self-reinforcing and vicious cycle of maladaptive thoughts and behavioral patterns has been set into place. Without appropriate treatment, it tends to persist over time.

Let’s see how CBT can put a stop to this dynamic.

How Does CBT Help With Social Anxiety?

The cognitive model of social anxiety has several components and not all of them can be modified. For example, we cannot change the fact that somebody experienced a traumatic social event in the past.

Likewise, we cannot directly and fully control the anxiety symptoms that may arise in certain social settings. Socially anxious people sometimes think they can, but the more they try to control them, the more these symptoms tend to overwhelm them.

However, there are certain components we have a direct influence over. This is precisely where CBT intervenes. By addressing the components we can directly influence, the anxiety symptoms reduce as a result.

CBT helps with social anxiety by changing the way people think and behave. It encourages to question and readjust negative beliefs, to focus on outward stimuli instead of internal sensations, to seek repeated exposure to the feared situations, and it teaches social skills when there is a deficit.

Have another look at the cognitive model of social anxiety below. The factors marked in red can be directly addressed through CBT. As a result, the anxiety symptoms can be reduced. However, as we have no direct influence over them, they are marked in orange.

Let’s have a look at how each of these interventions work and how they help breaking this cycle.

Cognitive Restructuring

The cognitive part of cognitive behavioral therapy addresses unhelpful thoughts and beliefs.

While everybody experiences them, they usually do not lead to any significant problems in our lives. However, for people with social anxiety they can cause tremendous trouble.

Let’s take Erica again as an example. She may be convinced to be unlikeable and worthless. If that’s the case, she is not only going to suffer from low self-esteem and crave other people’s approval, but she will also experience substantial anxiety whenever she is exposed to possible scrutiny.

According to CBT theory, a deeply rooted, negative core belief like this leads to specific intermediate beliefs. These can be seen as rules that need to be followed and as rigid attitudes about the self, others and the world.

For example, some of Erica’s intermediate beliefs may be:

“If others think I am insecure, they will dislike me.”

“I must always be in control of my emotions or I will be rejected.”

“I must appear confident to be seen as competent.”

“I cannot handle it if others reject or pity me.”

When Erica gets in a stressful social situation, such as giving a presentation at work, these intermediate beliefs trigger so-called automatic negative thoughts. These thoughts are specific to each situation and seem to pop up out of nowhere.

“I am getting super nervous. I will make a fool of myself.”

“They are laughing, probably about me.”

“I am shaking and they can see it. I must calm down.”

The following graphic depicts these three different levels of thoughts and beliefs. As you can see, the core belief fuels the intermediate beliefs, which in turn lead to automatic negative thoughts.

CBT attempts to change these three layers through cognitive restructuring (sometimes also called cognitive reframing).

It refers to a whole group of techniques that can help affected people identify and readjust their maladaptive thought patterns.

By exploring specific automatic negative thoughts, therapist and patient can uncover the underlying intermediate beliefs (attitudes and rules). From these, they can then deduct one or several core beliefs (fundamental assumptions about the self).

Once identified, the specific thoughts and beliefs are subject to a thorough examination. That is, patient and therapist set out to explore whether or not they are accurate and helpful.

If the patient decides they are neither, they can restructure their belief system and come up with more accurate and helpful ways of thinking.

The following are some techniques that can be used for cognitive restructuring:

• Socratic questioning (A series of questions that stimulate rational, logic thinking and help interrogate assumptions that are held to be true)
• Collecting evidence (Seeking and finding evidence for alternative beliefs helps adopting them)
• Looking for rational alternative explanations (Looking for different ways of explaining other people’s behavior instead of taking everything personal)
• Decatastrophizing (Combats the tendency of making a mountain out of a molehill)

With persistence and the help of an experienced therapist, cognitive restructuring has been found to reduce negative social cognitions and increase positive ones, which results in decreased social anxiety (Taylor et al., 1997).

In addition to cognitive reframing, the patient is educated about the adverse effects of focusing their attention on the self and on internal sensations.

Once they understand the harmful nature of such self-focused attention during a stressful social task, they are then instructed to direct their attention to outward stimuli, such as the task at hand. With time and practice, this leads to decreased self-consciousness in the feared situations.

Addressing the cognitive distortions and the harmful self-focus, the cognitive component of CBT addresses the following problematic aspects of the vicious cycle of SAD.

Exposure Exercises

The behavioral part of cognitive behavioral therapy addresses unhelpful and often maladaptive patterns in our behavior.

In the case of social anxiety, these are mainly avoidance of the feared situations as well as safety behaviors when facing them. CBT applies exposure exercises to approach these tendencies.

Exposure to the feared social situations is a major element of CBT for social anxiety. When carried out in the right way, it can have profound and often even quick anxiety-reducing effects. To be effective, exposure should be gradual, long enough, and repeated several times.

Let’s have a look at some important caveats when it comes to exposure exercises for social anxiety disorder.

SAD is often also referred to as social phobia. Phobic people are driven by their irrationally strong fear of an object or situation, which usually leads them to avoid the stimulus it is related to.

Interestingly, most phobic people understand that their anxiety reaction is neither logical nor helpful, but the fearful part of their brain tends to keep the upper hand.

The same is true for socially anxious people, as they oftentimes avoid the feared social settings altogether. However, outright avoidance of social situations is not always possible, and many affected people are quite brave and face the feared social scenarios despite opportunities to avoid them.

While other irrational fears, such as arachnophobia (phobic fear of spiders), diminish quite quickly once the affected person is repeatedly exposed to the feared stimulus, social anxiety is often maintained despite such efforts.

The main reason this happens is because of the safety behaviors we mentioned when introducing you to the cognitive model (Clark & Wells, 1995; Heimberg, Brozovich, & Rapee, 2014).

In our example, Erica lowered her head so her colleagues would not see her blush (among other things). She did so because she believed this would help her reduce the extent to which her co-workers would judge her as insecure.

However, not only did this behavior make her seem even more insecure, but it also got in the way of making a positive, corrective experience which could lower her social anxiety in future situations.

Because she avoided diect-eye contact, she was virtually blind to any positive social signals from her audience, such as a friendly smile, nodding heads, or the absence of people laughing about her performance.

By employing such safety behaviors, socially anxious people tend to get stuck in an seemingly endless anxiety loop, despite exposing themselves to the feared social settings.

Therefore, CBT therapists insist that exposure exercises should be carried out without the use of any behaviors that attempt to prevent a negative outcome or to reduce the extent of possible negative evaluation.

Before the patients actually realize exposure exercises, they are instructed to create an exposure hierarchy. It is a list of social situations and tasks that cause them to be socially anxious, ranging from mild anxiety to the most extreme.

Have a look at the following example of an exposure hierarchy for a person afraid of being the center of attention.

Note how the person started with situations she found only somewhat difficult (situations 1-3), then proceeded with situations she found significantly difficult (situations 4-7), and ended the list with situations that caused her severe anxiety (situations 8-10).

Once the hierarchy is created, the patient sets out to repeatedly seek these situations, starting at the bottom of the list. Oftentimes, especially in the beginning, the therapist accompanies the patient to carry out the exercises.

When doing so, the patient remains at one level until the anxiety has significantly decreased. That is, the patient repeatedly exposes themselves to the same social situation until it is no longer difficult to do so. Once that is the case, the next situation is tackled.

Through this gradual, repeated and controlled (no safety behavior) exposure to the feared stimuli, the brain quickly adapts and realizes that there is no real danger related to these situations.

Psychologists refer to this process as habituation and extinction learning. It can be regarded as the most important component of CBT for social anxiety.

Like this, the behavioral component of CBT addresses the harmful tendency of avoiding the feared social situations or of only facing them while trying to ward off any possible scrutiny by others.

Social Skills Training

Many people with SAD usually know what behavior would be socially appropriate, but simply struggle to put it into practice because they are overwhelmed by feelings of anxiety.

However, there is a subgroup of affected people who really do lack social skills. This is often the result of few opportunities to learn how to socialize during childhood.

Some may have had parents who isolated them from other children. Others might have been affected by an overly precautious and shy temperament, so that they never sought interaction with their peers.

But how are these deficits treated? Does CBT help with social skills?

Standardized CBT for social anxiety disorder does not address specific social skills, as most affected people know how socially appropriate behavior looks like. However, some people have actual deficits in their social abilities, which is then addressed through social skills training (SST).

To improve the patient’s social abilities, therapist and patient start by identifying the patient’s specific problem areas. Here are some examples:

• Starting, maintaining and ending a conversation.
• Being open and making a friendly impression when meeting others.
• Saying “no” and declining invitations.
• Complaining about something and being assertive.
• Using appropriate non-verbal behavior (posture, gestures, facial expressions, etc.)
• Engaging in small talk.

Once the areas have been identified, social skills related to these areas can be practiced through role play. The therapist may explain or model socially appropriate behavior and provide feedback that helps the patient fine-tune his social conduct.

Adding a SST component to CBT has been shown to be beneficial in terms of effectiveness (Beidel, Alfano, Kofler, & Rao, 2014). However, most people with SAD do not need this component to be included in treatment, as actual social skills deficits tend to be the exception.

How Effective is CBT for Social Anxiety Disorder?

Now that you have a good understanding of how CBT treats social anxiety, let’s see if it really works and have a look at its effectiveness.

A systematic review (2015) found that about 45-55% of people with social anxiety disorder (SAD) experience a significant symptom reduction following CBT treatment and a recent meta-analysis (2018) reported that about 40% no longer suffer from SAD after a standardized CBT intervention.

Both of these studies summarized the scientific findings indicating how many people with SAD experience a significant benefit from CBT treatment (Loerinc et al., 2015; Springer, Levy, & Toling, 2018).

While these numbers may seem low at first sight, keep in mind that response rates for psychological treatments of anxiety disorders are usually about 50%.

For those who do not respond to (or are not inclined to try) standard CBT, there are effective alternative approaches. We have summarized the different options in our complete treatment guide.

How Long Does CBT Take to Work for Social Anxiety?

CBT can reduce social anxiety within a matter of weeks, especially when exposure exercises are carried out soon into the treatment process and the patient adheres to the homework assignments. This way, CBT can work right from the moment of treatment initiation.

However, success of treatment is never guaranteed. People are different and they can respond differently to CBT.

About 45% of people who receive CBT treatment for their SAD experience significantly reduced social anxiety at the end of therapy (Loerinc et al., 2015).

Depending on the patient’s problems, the therapist and the treatment facility, the number of CBT sessions can vary widely. On average, CBT for social anxiety consist of about 12 sessions.

With time, the number of treatment responders tends to grow. For about 10% of people, the effects of CBT become significant a while after they have finished treatment.

If you are about to start a CBT intervention for your SAD and you want it to be effective as soon as possible, make sure you:

• open up to your therapist about your problems
• adhere to your homework assignments
• do the exposure exercises and repeat them often
• absorb as much as you can and ask questions
• focus on becoming your own ‘therapist‘ once you finish treatment

We hope this article solved any doubts you may have had. If we left any questions unanswered, please reach out and let us know. We will be happy to create the resource you are looking for.

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